Dr.

Reza Aminnejad

AIRWAY Assistant Professor Of

Anesthesiology & Critical

MANAGEMENT Care
Qom University Of Medical
Sciences
OBJECTIVES
Review aims of airway management
Review airway anatomy
Review airway examination
Review basic airway maneuvers
Review blind insertion airways
Review advanced airway techniques
AIMS OF AIRWAY
MANAGEMENT
Airway management in critical situations (life support)

Airway management in elective cases (surgical purposes)

UPPER AND LOWER
AIRWAYS
AIRWAY ANATOMY

Upper Airway Lower Airway

 Pharynx  Trachea
 Epiglottis  Bronchi
 Glottis  Alveoli
 Vocal cords  Lung tissue, consisting
 Larynx of lobes and lobules (3
on the right and 2 on
the left)
 Pleura
AIRWAY EXAMS
PMHx
Basic Physical Exam
Thyromental Distance
Mallampati Classification
Dr. Binnions “Lemon” Law (Look externally; Evaluate using
the 3:3:2 rule; Mallampati classification; Obstruction;
Neck mobility)
TMD
MALLAMPATI SCORE
CORMACK & LEHANE
GRADING
BASIC AIRWAY MANEUVERS

ALWAYS REMEMBER THE BASICS

These skills should be used prior to initiating any advanced
airway technique
 Head-tilt/chin lift
 Jaw thrust
 Modified jaw thrust (for trauma patients)
 Sellick’s maneuver
MODIFIED JAW THRUST
MANEUVER
SELLICK’S MANEUVER
OROPHARYNGEAL AIRWAY

Size is measured from the corner of the mouth to the angle of

the jaw
Sizes range from 0-6
It holds the tongue away from the posterior pharynx, but does
not isolate the trachea
ORAL AIRWAY INSERTION
TECHNIQUE
ORAL AIRWAY CONTINUED
The oral airway is
inserted with the curve
towards the side of the
mouth
Then rotated so that
the curve of the airway
matches the curve of
the tongue
NASOPHARYNGEAL AIRWAY

Soft plastic or rubber tube that is designed to

pass just inferior to the base of the tongue
Passed through one of the nares and can be
used in patients with an intact gag reflex
CONTRAINDICATED in cases of suspected or
possible basilar skull fracture
Sizes range from 17-26 cm in length and 6-9
mm internal diameter
Measured from tip of the nose to the corner of
the patients ear
INSERTION TECHNIQUE OF
NPA
NASAL AIRWAY CONTINUED
The nasal airway is
lubricated with a water
soluble lubricant
The beveled tip is inserted
directed towards the
septum, with the airway
directed perpendicular to
the face
If resistance is met,
rotating the airway may
help or the other nare may
be used
BLIND INSERTION AIRWAYS

Combi-tube Blind insertion airways

considered an alternative
LMA (Laryngeal Mask airway control device to be
Airway) used when intubation is
King Airway unsuccessful
They do not require
visualization of the vocal
cords
COMBITUBE®
COMBI-TUBE
This is a multi-lumen airway that works whether
it is inserted into the esophagus or the trachea
It either blocks the esophagus above and below
the glottic opening or by directly ventilating the
trachea
Contraindicated in patients under 5 foot tall or
those under 14 years old, in patients who have
ingested caustic substances, patients with
esophageal trauma or disease, and in patients
with an intact gag reflex
COMBITUBE PLACEMENT
LARYNGEAL MASK AIRWAY
Sits over the glottic
opening
Available in different sizes
Has a drain tube to aid in
gastric suctioning
With some versions an
endotracheal tube may be
passed through to aid in
intubation
LMA POSITIONING
LMA CLASSIC
Designed in 1981 by Dr Archie Brain
Specified in difficult airway management
Can not protect aspiration
Can not be used for pulmonary toilet
On insertion the Backward folding of the cuff (tip roll) causes
resistance
LMA is Less Stimulating than ETT
Remove it awake in adults and deep in children
LMA ADVANTAGE
Rapidity and ease of placement
Improved hemodynamic stability
Minimal rise in intraocular pressure
Reduced anesthesia requirements
Reduced cough on emergence
Lower incidence of sore throat in adults
Its utility in difficult intubation
LMA DISADVANTAGES
No protection against aspiration
Gastric insufflations
Air leak with positive pressure ventilation
 LMA FLEXIBLE (FLMA)
Similar in design to classic but non kink able used in ENT, head and
neck and dental surgeries.
INTUBATING LMA
LMA FASTRACK (ILMA)

Designed by Dr Brain
Reusable, easy to use, and high success
rate
Intubation may be difficult if mouth opens
less than 20 mm
Its better to withdraw the device after
intubation
 ILMA
Ventilation and intubation can be successfully
achieved in obese patients (BMI >30)
Accepted in guideline of unanticipated difficult
airway in non obstetrical patents
LMA PROSEAL
PLMA
Is expected to reduce aspiration risk (0.02%)
Intra cuff pressure is lower and seal better than LMA
Less gastric insufflations
PEEP can safely be applied by PLMA
It is more difficult to place than LMA
Seals better than LMA
Suitable for longer duration surgeries
Esophageal conduit permits passage of a gastric tube
LMA SUPREME
 LMA SUPREME
Sealling pressure is like PLMA
Ease of intubation is like CLASSIC
Single use as unique
Has drainage tube as PLMA
Latex free
Candidate for CPR
IGEL
IGEL
Single use thermoplastic device in size 3-5
There is no cuff
Has a gastric drainage
Seals better than Proseal and LMA (but if there is a leak you
must change the iGEL)
Drainage tube of iGEL is smaller than Proseal
iGEL is the easiest EGD to insert (98%)
COMBITUBE (CBT)
Easily inserted highly efficacious device
Primary rescue device in CVCI
Successfully used in CPR
Has 2 rings on proximal end that upper teeth are situated
between them
Size 37F for adults with height of 120-180cm and 41F for
tallers
Distal balloon needs 10 cc & proximal one needs 80-100 cc air
for insuflation
It enters to the esophagus in 95% of cases
CBT
May be kept in place for 8 hours and allows high pressure
ventilation (50 cmH20)
Can be used in bleeding and aspiration situations
Does not need neck extension for insertion (it only requires
modest mouth opening)
Doesn't need any cervical manipulation
DISADVANTAGES OF CBT
Suction of trachea is impossible with CBT
Complications such as subcutaneous emphysema,
pneumomediastinum and pneumoperitoneum should be
considered.
Esophageal rupture and tongue engorgement are rare
LARYNGEAL TUBE
LARYNGEAL TUBE
LARYNGEAL TUBE (LT)
Silicon airway tube
Requires 23mm mouth opening
Has single inflation pilot balloon apparatus
Amount of air needed depends on size and is indicated on a
syringe that is included
Cuff pressure should be limited to 60cm H20
Its is very easy to insert, black line on proximal part shall align
upper teeth
LARYNGEAL TUBE

ADVANTEGES DISADVANTEGES
Easy to insert Aspiration protection
Non traumatic is less than offered
Good seal Cuff pressure may
increase in
Adequacy of ventilation concomitant N2O
Efficient use in children usage
>2y LMA is better in
Protection of GE-Reflux children under 10
years
AIRWAY MANAGEMENT
DEVICE
AIRWAY MANAGEMENT
DEVICE
(AMD)
Is a clear silicon dual lumen tube
Proximal port is y shaped )one a channel to esophagus and
second for delivering anesthetic gases)
Esophageal cuff should filled with 5-9 cc air
Pharyngeal cuff needs 50-80 cc air for full filling
It is available in 3-3.5 size for a 30-60 kg patient
Size 4-5 for patients weighing >60 kg
It is hard to insert successfully in 66% cases at the first time
Loss of airway during anesthesia has been reported
COBRA TUBE
COBRA PLA
Cobra shaped EGDs are available in eight sizes (3 for females
& 4 for males)
Cobra PLUS has a temperature probe and a gas sampling line
for pediatric patients
It Should be removed awake (while reflexes are intact)
COBRA PLA

Advantages Disadvantages

larger lumen takes longer to insert

can be used as ETT no reflux protection
conduit
seals better than
LMA
is better in limited
mouth opening
SLIPA TUBE
SLIPA IN PLACE
SLIPA

Designed by Dr. Miller (South Africa)

Soft plastic hallow boot shaped with heel
Has higher rate of gastric insufflations (19%) compared to LMA (3%)
CUFFED OROPHARYNGEAL
AIRWAY
 CUFFED OROPHARYNGEAL
AIRWAY
COPA
Is modified GUDEL airway with a distal cuff and a 15mm connector
Described in 1992 for spontaneously breathing patients (no longer
manufactured)
LMA TAKE-HOME POINTS
Test cuff before use
Don’t lubricate anterior mask
Insert only in comatose patient
Keep cuff inflated until patient awake
ADVANCED AIRWAYS
Orotracheal Intubation
Nasotracheal Intubation
Digital Intubation
Surgical Airways
INDICATIONS OF
INTUBATION
Airway protection
Maintaining oxygenation
Continuing ventilation
Delivering some drugs
Anticipating upcoming needs
DIFFICULT INTUBATION
What should be
Definition
considered?
If proper tube insertion needs Need for help
more than 3 consecutive
attempts Awake intubation

or Appropriate equipments

If proper tube insertion Plan B

prolongs more than 10
minutes.
 OROTRACHEAL INTUBATION
Requires direct visualization of the vocal cords
with the use of a laryngoscope
Completely isolates the esophagus from the
trachea
At least two forms of placement verification are
required
 Physical assessment (color improvement, equal breath
sounds, absence of gurgling over epigastrium, and direct
visualization of tube passing through cords)
 End-tidal CO2 detector
 Esophageal detector device (EDD)
PATIENT PREPARATION
Patient should be informed of the risk & the planning of
intubation (awake)
Premedication (atropine/sedatives)
An assistant should be available
WHAT YOU NEED FOR
INTUBATION
BLADE TYPES
 OROTRACHEAL INTUBATION
PROCEDURE
Assemble all needed equipment, while patient is
being ventilated
 Choose appropriate ET tube size
 Check balloon with 10cc of air
 Place stylet, stopping approximately ½ inch short of the
end of the tube (optional)
 Assemble laryngoscope and check it’s light
 Connect and check suctioning device
Put the patient in “sniffing” position (neck flexed
forward, head extended back, and back of head
should be level with or above the shoulders).
If cervical spine injury is suspected have an
assistant hold the patient’s head in a neutral
position.
SNIFFING POSITION
INTUBATION (CONTINUED)
Pre-oxygenate the patient with 100% oxygen
Insert laryngoscope to right of the midline. Move to
midline, pushing the tongue to the left.
Lift straight up on the blade to expose posterior
pharynx.
Identify the epiglottis; tip of curved (Macintosh)
blade should sit in valeculla (in front of the
epiglottis), straight blade should slip over the
epiglottis. With further, gentle traction, identify
trachea and arytenoid cartilages and vocal cords
Insert ET tube along the blade, into the trachea and
advance the tube 1-1.5 inches beyond the cords
and inflate the cuff.
INTUBATION (CONTINUED)

Ventilate and watch for chest rise and fall.

Listen for breath sounds, over stomach, four
lung fields and axillae. (If breath sounds are
diminished or absent on left side, indicating a
right mainstem intubation, slightly pull tube back
and reassess breath sounds).
Note number on the side of the ET tube at the
central incisor and secure the tube.
Reassess breath sounds, now and any time the
patient is moved.
NASOTRACHEAL INTUBATION

Can be done blind or with

the aid of a laryngoscope.
If done blind, the patient
must be breathing.

Cannot be performed on
patients with a suspected
basilar skull fracture.
Can be performed on
patients with an intact gag
reflex.
DIGITAL INTUBATION
Useful in the absence of
necessary equipment & as
an alternative when other
more conventional methods
for intubation have failed

Head manipulation is
minimal.

Performed by physically
finding the epiglottis with
middle and index fingers,
and then sliding the tube
interiorly into the trachea.
FAILED INTUBATION
A. FLEXIBLE FIBEROPTIC
SCOPE
FIBEROPTIC
LARYNGOSCOPY
FLEXIBLE FIBEROPTIC
SCOPE
Advantages
Allows direct airway visualization
Causes little hemodynamic stress
Nasotracheal or orotracheal route can be used
Can be done in all age groups
Requires minimal neck movements
FLEXIBLE FIBEROPTIC
SCOPE
Disadvantages
Expensive
Expertise requires practice
Delicate equipment needs careful maintenance
Visual field easily impaired by blood and secretions
B. RIGID FIBEROPTIC
SCOPE
 FIBEROPTIC STYLETS
Bonfils nonmalleable tubes
Shikani semi malleable tubes
Levitan FPS scope
Fiberoptic Stylet Scope
 FIBEROPTIC
LARYNGOSCOPES
Bullard Laryngoscopes
Upsher Scope
AIRTRAQ
RIGID VIDEO
LARYNGOSCOPES
V/MAC AND C/MAC
GLIDESCOPE
RIGID VIDEO
LARYNGOSCOPES
are simple to use/ no wires/ portable
low cost/ compact and light weight
easy insertion/ no damage
good exposure/ high success rate
non problematic tube passage
works well with restricted neck movement
fogging is not a limitation
are very useful in morbid obese patients and low grade
Cormack score
RIGID FIBEROPTIC
LARYNGOSCOPES
they have working channel
allow visual controlled ETT insertion
give wider visual field
anatomical field more identifiable
fogging and secretions are still problematic
does not need extended cervical extension
they give superior glottic view but directing ETT is an
obstacle to success
RIGID FIBEROPTIC
SCOPE
Advantages
Direct airway visualization
Minimal neck movement
May overcome difficult view
Useful in disrupted airway
Durable, sturdy instruments
RIGID FIBEROPTIC
SCOPE
Disadvantages
Expensive
Expertise requires practice
Visual field easily impaired by blood and secretions
Not readily available
High Success Rate Low
Cost Bougie
C. LIGHTWAND
(TRACHLIGHT)
 LIGHTWAND
(TRACHLIGHT)
 LIGHTWAND
(TRACHLIGHT)
Disadvantages
Blind technique
May damage airway
Usually requires darkened room
Expertise requires practice
NU-TRAKE
Surgical airways
should only be used
when all other
methods have been
exhausted
It is not intended for
children under the age
of 5 years old.
SUMMARY
Always remember the ABCs, without an airway your patient will
not survive.
There are several ways to manage a patient’s airway.
Don’t forget the basics, all your patient may need is for
someone to open their airway, to start improving.
IT’S NOT OVER …
Any question?
MANY THANKS FOR
YOUR KIND
ATTENTION
Many thanks to Dr. S.
Malek for sharing his
valuable slides on this
topic.